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� <br />� <br />Backwater Preventfon Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: T <br />U <br />Installation Address: S � S �T�.� K I� ►� U6 <br />c�cy: .�U�/�, �� state: w N z;p: 95.2 �( <br />Malling Address (il dillerenf): <br />City: <br />Email: <br />State: <br />Zip: <br />Pn,ne: (yzSJ' 2S2 -G �vZ <br />Total Cost to Install Device (fiom crontracfor invoiee): S�4.�i .�'�C <br />Please verify the /ollowing: <br />� am the owner of the'property where the backwater prevenNon device was Installed. <br />��I worked with the contracta to determine fhe location.for ihe backwater prevention device and <br />undersland that the decision•regarding,lhe location of the device was mine. <br />[�My contractor instruded me how lo access, inspect, and mafntain the device. <br />[� I understand lhat I am respons'�ble tor maintaining the badcwater preverition device end keeping <br />it in good working order, unless it fs inslalled in the city righ4of-way. <br />[�j'If 1 sell my propeAy, I will make potenlial buyers aware of ihe backwater prevention device and <br />the need lo inspect and ma�ntain it on a regular 6asis. <br />�am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select hom•lhe followinp: <br />�The conVactor idenlified downspouls or other drainage Ilines that were connected to my sewer <br />line (betwea� my house and (he installed device) and removed, or rerouted ihem. <br />[�To my knowledge, my property has no downspouls or other drainage connected to my sewer line <br />(between my house and the installed devke). <br />❑ There are downspouts or otheadrainage lines connected to my sewer line (betweemmy house <br />and.the inslalled device)..I�understa�d thal leaving these connections creates a risk of Ilooding <br />and�l accept that risk. <br />Signature /��?'��- `��� � Data �� �� � <br />